Preterm birth affects approximately one in every ten neonates. The clinical outcomes depend on care and management factors, including the birth delivery method and the use of antibiotics. This observational cohort study determined antimicrobial peptides, proteases, metabolomic, and microbiome profiles in fecal samples collected from 20 preterm and nine full-term neonates 48 h after birth. The results show that preterm neonates have increased levels of α-defensins, serine proteases, and matrix metalloproteinases. They also have distinct metabolic signatures characterized by decreased kynurenic acid and increased mevalonate levels. These neonates also exhibit reduced microbial diversity. This study highlights that heightened immune response and proteolytic activity, marked dysbiosis, and reduced short-chain fatty acids within the preterm gastrointestinal tract immediately after birth might predispose neonates to exacerbated gut inflammation. Some of the findings, including the elevated fecal mevalonate levels, are potential biomarkers in neonatology for early identification of metabolic disturbances linked to gut inflammation, emphasizing further studies to explore its association with inflammatory conditions in preterm infants.

ObjectiveTo compare the length of hospitalization for moderate and late preterm infants (MLPIs; 320/7-366/7 weeks gestation) born at tertiary care (level III) perinatal centers versus secondary care perinatal centers (level II).MethodsThis was a retrospective cohort study of all MLPIs born at one of four perinatal centers (one tertiary and three secondary) in Calgary, Canada. All preterm infants born before 360/7 were routinely admitted to neonatal intensive care units (NICUs). We excluded infants with major congenital anomalies and those receiving planned palliative care. Multivariable logistic, propensity score-matched, and quantile regression analyses were used to adjust for potential confounding factors.ResultsOf the 1958 infants who met inclusion criteria, 676 (34.5%) infants were born at a tertiary care perinatal center with a level III NICU, and 1284 (65.5%) were born in secondary care perinatal centers with a level II NICU. The average gestational age was 34.8 weeks. Infants born at level II centers had shorter durations of hospital stay (adjusted mean difference [aMD] -1.0 day; 95% CI -1.7, -0.4) and tube feeding (aMD -2.2 day; 95% CI -2.9, -1.4), a lower need for peripheral intravenous access (adjusted odds ratio (aOR) 0.66; 95% CI 0.53, 0.83), reduced use of infant formula during hospitalization (aOR 0.58; 95% CI 0.43, 0.78), and a higher rate of breastmilk feeding at discharge (aOR 1.34; 95% CI 1.01, 1.77).ConclusionDelivery of MLPIs in secondary care perinatal centers is associated with shorter hospital stays and higher breastmilk feeding rates at discharge.

Importance:Providing assisted ventilation during delayed umbilical cord clamping may improve outcomes for extremely preterm infants. Objective:To determine whether assisted ventilation in extremely preterm infants (23 0/7 to 28 6/7 weeks' gestational age [GA]) followed by cord clamping reduces intraventricular hemorrhage (IVH) or early death. Design, Setting, and Participants:This phase 3, 1:1, parallel-stratified randomized clinical trial conducted at 12 perinatal centers across the US and Canada from September 2, 2016, through February 21, 2023, assessed IVH and early death outcomes of extremely preterm infants randomized to receive 120 seconds of assisted ventilation followed by cord clamping vs delayed cord clamping for 30 to 60 seconds with ventilatory assistance afterward. Two analysis cohorts, not breathing well and breathing well, were specified a priori based on assessment of breathing 30 seconds after birth. Intervention:After birth, all infants received stimulation and suctioning if needed. From 30 to 120 seconds, infants randomized to the intervention received continuous positive airway pressure if breathing well or positive-pressure ventilation if not, with cord clamping at 120 seconds. Control infants received 30 to 60 seconds of delayed cord clamping followed by standard resuscitation. Main Outcomes and Measures:The primary outcome was any grade IVH on head ultrasonography or death before day 7. Interpretation by site radiologists was confirmed by independent radiologists, all masked to study group. To estimate the association between study group and outcome, data were analyzed using the stratified Cochran-Mantel-Haenszel test for relative risk (RR), with associations summarized by point estimates and 95% CIs. Results:Of 1110 women who consented to participate, 548 were randomized and delivered infants at GA less than 29 weeks. A total of 570 eligible infants were enrolled (median [IQR] GA, 26.6 [24.9-27.7] weeks; 297 male [52.1%]). Intraventricular hemorrhage or death occurred in 34.9% (97 of 278) of infants in the intervention group and 32.5% (95 of 292) in the control group (adjusted RR, 1.02; 95% CI, 0.81-1.27). In the prespecified not-breathing-well cohort (47.5% [271 of 570]; median [IQR] GA, 26.0 [24.7-27.4] weeks; 152 male [56.1%]), IVH or death occurred in 38.7% (58 of 150) of infants in the intervention group and 43.0% (52 of 121) in the control group (RR, 0.91; 95% CI, 0.68-1.21). There was no evidence of differences in death, severe brain injury, or major morbidities between the intervention and control groups in either breathing cohort. Conclusions and Relevance:This study did not show that providing assisted ventilation before cord clamping in extremely preterm infants reduces IVH or early death. Additional study around the feasibility, safety, and efficacy of assisted ventilation before cord clamping may provide additional insight. Trial Registration:ClinicalTrials.gov Identifier: NCT02742454.

OBJECTIVE To compare the length of hospital stay for moderate and late preterm infants (MLPIs) born at tertiary care (level III) perinatal centers versus secondary care perinatal centers (level II). METHODS This was a retrospective cohort study of MLPIs admitted to neonatal intensive care units (NICUs) in Calgary, Canada, between January 2016 and December 2017. We excluded infants with major congenital anomalies and planned palliative care. Multivariable logistic and quantile regression analyses were used to adjust for potential confounding factors. RESULTS Of 1958 infants who met inclusion criteria, 676 (34.5%) infants were born at a tertiary care perinatal center with a level III NICU, and 1284 (65.5%) were born in secondary care perinatal centers with a level II NICU. Infants born at level II centers had shorter durations of hospital stay (adjusted MD -1.0 day, 95% CI -1.7 to -0.4 and adjusted HR 1.15, 95% CI 1.04 to 1.28) and tube feeding (adjusted MD -2.2 day; 95% CI -2.9 to -1.4), and a higher rate of breastmilk feeding at discharge (aOR 1.34; 95%CI 1.01 to 1.77). CONCLUSION Delivery of MLPIs in facilities with secondary care perinatal centers is associated with shorter hospital stays and higher breastmilk feeding rates at discharge.

Hypoxic-ischemic encephalopathy (HIE) and associated multiorgan injury are significant causes of morbidity and mortality in term and near-term neonates. Therapeutic hypothermia (TH) is the current standard of care for neuroprotection in neonates with HIE. In our experience, the majority of babies born with HIE were found in nontertiary care facilities in our region, where effective methods of cooling during transport to tertiary care centers are desirable. Most centers initiate passive TH at referral hospitals, while active cooling is typically initiated during transport. The objective of this study was to evaluate the effectiveness of three methods of cooling during transport of neonates with HIE in southern Alberta. In this prospective cohort study, 186 neonates with HIE were transported between January 2013 and December 2021. Among the 186 neonates, 47 were passively cooled, 36 actively cooled with gel packs, and 103 cooled with a servo-controlled cooling device. The clinical characteristics were comparable for the three groups, with no difference in adverse events. Fifteen neonates (8%) died and 54 neonates (29%) suffered radiologically determined brain injury. Servo-controlled cooling was found to be superior to other methods in maintaining a target temperature without significant fluctuation during transport and with temperature in the target range on arrival at tertiary care facilities. The rate of overcooling was also lower in the servo-controlled group compared with other groups. There were no statistically significant differences between the groups in relation to mortality and brain MRI changes associated with HIE. Adjusting for GA, 10-minute Apgar score, base excess, HIE stage, and need for intubation during transport, passive cooling increased the odds of temperature fluctuation outside the range by 12-fold and gel pack cooling by 13-fold compared with servo-controlled cooling. The use of servo-controlled TH devices should be the preferred practice wherever feasible. (REB17-1334_REN3).

Objective In 2019 the Southern Alberta Neonatal Transport Service adopted a transport call handling process change to expedite transport team mobilization. This study compares the impact of this change on neonatal transport decision to dispatch and mobilization times.Study Design This retrospective cohort study was conducted using a historical cohort of neonates referred for transportation between January 2017 and December 2021. The "dispatch time" (DT) was the time from the start of consultation to the time a decision to dispatch the transport team was made, whereas "mobilization time" (MT) referred to the time from start of consultation to the time the team departed the home base. In 2019, a DT target of <3 minutes was implemented to meet a target MT of <15 and <30 minutes for emergent and urgent high-risk transport referral calls, respectively. In 2021 use of the "Situation" component of the SBAR (Situation, Background, Assessment, Recommendation) communication tool was introduced with the transport team asking five questions to determine need for mobilization. Data between 2017 and 2018 represented the preintervention period, 2019, the "washout" period for implementation, and 2020 to 2021, the postintervention period. Data were analyzed to determine trends in DT and MT.Results The DT was reduced from a median of 5 to 3 minutes following intervention ( p < 0.001). DT target goal of 3 minutes was achieved in 67.08% of calls compared with 26.24% in the preintervention period, ( p < 0.001). The team achieved MT target goals in 42.71% of urgent and emergent transfers compared with 18.05% prior to intervention ( p < 0.001).Conclusion Introduction of a time-sensitive referral call handling process improved dispatch and mobilization time of the neonatal transport team.

Introduction:Prolonged periods spent outside the target range of oxygen saturation (SpO(2)) in preterm infants, along with frequent desaturation events, predispose them to retinopathy of prematurity (ROP) and long-term neurodevelopmental impairment. The primary aim of this study was to increase the mean time spent within the target SpO(2) range (WTR) by 10% and to reduce the frequency of desaturation events by 5 events per patient day, respectively, within 18 months of implementing a care bundle. Methods:This study was completed in a 46-bed neonatal intensive care unit (NICU), involving 246 staff members and led by a quality improvement team. The change interventions included implementing new practice guidelines, reviewing daily summaries of SpO(2) maintenance, daily infant wellness assessment, standardizing workflow, and responding to SpO(2) alarms. In addition, we collected staff satisfaction and compliance with change interventions, resource use, and morbidity and mortality data at discharge. Results:The mean time spent WTR increased from 65.3% to 75.3%, and the frequency of desaturation events decreased from 25.1 to 16.5 events per patient day, respectively, with a higher magnitude of benefit in infants on days with supplemental oxygen. Postimplementation, the duration of high-frequency ventilation and supplemental oxygen were lower, but morbidity and mortality rates were similar. Staff satisfaction with training workshops, coaching, use of the infant wellness assessment tool, and SpO(2) alarm management algorithms were 74%, 82%, 80%, and 74%, respectively. Conclusion:Implementing a care bundle to improve oxygen maintenance and reduce desaturation events increased the time spent WTR and reduced the frequency of desaturation events.

Objective To study the impact of an evidence-based neuroprotection care (NPC) bundle on long-term neurodevelopmental impairment (NDI) in infants born extremely premature. Study design An NPC bundle targeting predefined risk factors for acute brain injury in extremely preterm infants was implemented. We compared the incidence of composite outcome of death or severe neurodevelopmental impairment (sNDI) at 21 months adjusted age pre and post bundle implementation. Results Adjusting for confounding factors, NPC bundle implementation associated with a significant reduction in death or sNDI (aOR, 0.34; 95% CI 0.17–0.68; P = 0.002), mortality (aOR, 0.31; 95% CI (0.12–0.79); P = 0.015), sNDI (aOR, 0.37; 95% CI: 0.12–0.94; P = 0.039), any motor, language, or cognitive composite score <70 (aOR, 0.48; 95% CI: 0.26–0.90; P = 0.021). Conclusion Implementation of NPC bundle targeting predefined risk factors is associated with a reduction in mortality or sNDI in extremely preterm infants.

Objective: To determine the association between the degree of intrauterine growth restriction (IUGR) [defined by birth weight (BW) Z-score] and the efficacy of pharmacologic patent ductus arteriosus (PDA) closure and the rate of surgical PDA ligation in preterm neonates. Materials and methods:In this retrospective cohort study, we included neonates born below 30 weeks' gestational age (GA), who received medical treatment for PDA between January 2010 and December 2018.Birth weight Z-scores were calculated using Olsen nomograms and classified into three categories: above -0.5;from -0.5 to -2.0; below-2.We compared responses to PDA treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and PDA ligations between these groups utilizing multivariable logistic regression analysis.Results: Of 769 neonates with PDA, 517 (67.2%) neonates received medical treatment for PDA.Of which, 323 (62.5%) had BW Z-score above -0.5, 154 (29.8%) had from -0.5 to -2.0., and 40 (7.7%) had below -2.The efficacy of the first course of NSAIDs for the PDA closure was not different among the three groups (51% vs 49% vs 50%).Multivariable logistic regression analysis showed there was no significant difference in PDA closure rate following the first course of NSAIDs between neonates with BW Z-score below -2 and those with BW Z-score above -0.5 [adjusted odds ratio (aOR): 0.68; 95% CI: 0.33-1.39]as well as those with BW Z-score from -0.5 to -2.0 (aOR: 0.89; 95% CI: 0.59-1.35).However, the odds of PDA ligation were significantly higher among neonates with BW Z-scores below -2 (aOR: 2.67, 95% CI: 1.12-6.34)but not among neonates with Z-scores from -0.5 to -2.0 (aOR: 1.41; 95% CI: 0.84-2.39),as compared to those with BW Z-scores above -0.5. Conclusion:We observed a similar rate of PDA closure following the first course of NSAIDs between appropriately grown and growth-restricted neonates.However, severe growth restriction (BW Z-score below -2) is associated with higher rates of PDA ligation as compared to normally grown infants.

Objective To evaluate impact of a quality improvement (QI) outreach education on incidence of acute brain injury in transported premature neonates. Study design Neonates born at <33 weeks gestation outside the tertiary center were included. The QI intervention was a combination of neuroprotection care bundle, in-person visits, and communication system improvement. Descriptive and regression (adjusting for Gestational Age, Birth Weight, Gender, and antenatal steroids, Mode of delivery, Apgars at 5 minutes, Prophylactic indomethacin, PDA, and Inotropes use) analyses were performed. The primary outcome was a composite of death and/or severe brain injury on cranial ultrasound using a validated classification. Results 181 neonates studied (93 before and 88 after). The rate and adjusted odds of death and/or severe brain injury reduced significantly post intervention (30% vs 15%) and (AOR 0.36, 95%CI, 0.15–0.85, P = 0.02) respectively. Conclusion Implementation of outreach education targeting neuroprotection can reduce acute brain injury in transported premature neonates.

Abstract Background Consensus on definition and management of hypotension in preterm neonates is lacking. Owing to this, there are wide variations in the reported incidence of hypotension in premature infants, especially during first week of life. Inotropes can often cause vasoconstriction, which may alter brain perfusion especially in the absence of established cerebral autoregulation. Use of these drugs is associated with multiple short- and long-term morbidities. Objectives To evaluate the effect of quality improvement (QI) bundle on rate of inotrope use and associated morbidities. Design/Methods Inborn preterm neonates born at <29weeks gestational age (GA) and admitted to level III NICU were included. Neonates with major congenital malformations, congenital heart diseases, antenatal diagnosed genetic defects, and neonates admitted after 72 hours of age were excluded from the study. We implemented a QI bundle (Figure 1) focussing on first 72hours from birth which included delayed cord clamping, avoidance of routine echocardiography, addition of clinical criteria to define hypotension, factoring iatrogenic causes of hypotension (ruling out lung hyperinflation), and standardization of respiratory management. Rate of use of inotropes in the first 72hours of life along with acute brain injury and mortality before and after implementation of the QI bundle were compared. The balancing measure was the rate of ischemic lesions in the form of cPVL. Cranial ultrasound was performed to screen for brain injury. Study was approved by the local research ethics board (REB14-1466). Results We included 671 neonates (301 before and 364 after the implementation of the bundle) among which 6 neonates were excluded based on the criteria. QI bundle implementation was associated with significant reduction in overall use of inotropes (24% vs 7%, p<0.001), dopamine (18% vs 5%, p<0.001), and dobutamine (17% vs 4%, p<0.001). Rate of acute brain injury decreased significantly: Acute brain injury of any grade (34% vs 20%, p<0.001) and severe brain injury (15% vs 6%, p<0.001). There was no difference in incidence of cPVL (1% vs 1.4%, p=0.66). Associations remained significant after adjusting for confounding factors. The QI bundle implementation was associated with a significant reduction in the use of inotropes when analyzed based on the 6 monthly time intervals (p = 0.006) (Figure 2) Conclusion Our QI bundled approach resulted in reduction in inotrope use and associated brain morbidities in premature babies. Follow-up studies evaluating the impact of this initiative on long-term outcomes in survivors are required to complement findings of improved short-term outcomes seen in this study.

Background We evaluated the effect of the quality improvement (QI) bundle on the rate of inotrope use and associated morbidities. Methods We included inborn preterm neonates born at < 29 weeks admitted to level III NICU. We implemented a QI bundle focusing on the first 72 h from birth which included delayed cord clamping, avoidance of routine echocardiography, the addition of clinical criteria to the definition of hypotension, factoring iatrogenic causes of hypotension, and standardization of respiratory management. The rate of inotropes use was compared before and after implementing the care bundle. Incidence of cystic periventricular leukomalacia (cPVL) was used as a balancing measure. Results QI bundle implementation was associated with significant reduction in overall use of inotropes (24 vs 7%, p < 0.001), dopamine (18 vs 5%, p < 0.001), and dobutamine (17 vs 4%, p < 0.001). Rate of acute brain injury decreased significantly: acute brain injury of any grade (34 vs 20%, p < 0.001) and severe brain injury (15 vs 6%, p < 0.001). There was no difference in the incidence of cPVL (0.8 vs 1.4%, p = 0.66). Associations remained significant after adjusting for confounding factors. Conclusions A quality improvement bundled approach resulted in a reduction in inotropes use and associated brain morbidities in premature babies.

Objective We determined intra- and inter-rater agreement for umbilical arterial/venous catheter (umbilical arterial catheter [UAC] and umbilical venous catheter [UVC], respectively) positions on supine anteroposterior (AP) and horizontal dorsal decubitus (HDD) X-ray views to determine whether two views are routinely required. Study Design This retrospective study was conducted in McMaster University, Canada. Pairs of AP and HDD radiographs were coded and rated in random sequence by two experienced raters. Primary outcome was intra-rater agreement ( kappa ) between AP and HDD views for UVC catheter tip position. Secondary outcomes included inter-rater kappa for UVC position; inter- and intra-rater kappa for UAC position, inter- and intra-rater kappa for follow-up action. To detect kappa of 0.8 (width of 95% confidence interval=0.1), 138 radiograph pairs were required. Results Intra-rater agreement tended to be higher for UVC versus UAC position (Rater#1: kappa = 0.44 vs. 0.16, respectively, p =0.08; and #2: kappa = 0.56 vs. 0.47, respectively, p =0.5). Inter-rater agreement was higher on AP versus HDD view for UVC position ( kappa = 0.6 vs. 0.29, respectively, p =0.03) and action recommended for UVC ( kappa = 0.61 and 0.19, respectively, p <0.001). Conclusion AP is superior to HDD view for UVC.

Our primary objective for this follow-up study was to compare the neurodevelopmental outcomes of a surviving cohort of infants using a split-week gestational model (early versus late) gestational age (GA) and the standard completed GA categorization. Neurodevelopmental outcomes using a split-week GA model defined as early (X, 0–3) and late (X, 4–6), with X being 23–26 weeks GA, were compared to outcomes using completed weeks GA. In total, 1012 infants were included in the study. Statistically significant differences were noted in outcomes between the early and late split of the gestational week at 23 weeks (early vs. late), with 13.3% vs. 54.5% for no neurodevelopmental impairment, and 53.3% vs. 22.7% for significant impairment (p = 0.034), respectively. There were no differences seen in the split week model for 24, 25, and 26 weeks. A trend towards improved neurodevelopmental outcomes was seen with each increasing gestation week. The split-week model did not provide additional information for pregnancies and infants between 24 and 26 weeks gestation. It did, however, provide information for counsel for infants at 23 weeks gestation, showing benefits in the late versus early half of the week.

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Preterm infants who are also intrauterine growth restricted (IUGR) experience more frequent and earlier hemodynamic consequences of patent ductus arteriosus (PDA). This may be related to altered levels of prostaglandins or altered number or sensitivity of their receptors in IGUR infants. Few studies have examined the efficacy of pharmacologic therapy (non-steroidal anti-inflammatory drugs [NSAIDs]: indomethacin, ibuprofen, or acetaminophen) for PDA closure among preterm infants based on their degree of IUGR with differing results. Objectives Primary: To determine if the degree of IUGR [defined by birth weight (BW) z-score] affects the efficacy of pharmacologic PDA closure and rate of surgical PDA ligation in preterm infants. Secondary: To compare the side effects of NSAIDs and neonatal outcomes based on the severity of IUGR. Design/Methods This retrospective cohort study included infants of < 30 weeks’ GA, admitted to a tertiary neonatal intensive care unit (NICU) between 2010 and 2018, with hemodynamically significant PDA and treated with NSAIDs. Infants with major congenital anomalies, those who received prophylactic Indomethacin and those who died in the first 48 hours were excluded. Birth weight (BW) z-scores were calculated using Olsen nomograms and classified into 3 categories: z-score > −0.5 (normal), z-score −0.5 to −2.0 (mild to moderate growth restriction), z-score <−2 (severe IUGR). We compared responses to NSAID treatment and PDA ligation. Multivariate logistic regression analysis was done to examine the association of BW z-score and response to pharmacological therapy and subsequent surgical PDA ligation. Results Of the 1511 eligible infants, 769 (51%) had a diagnosis of PDA. Of 517 included infants, 323 (62.5%) had BW z-score >− 0.5, while 154 (29.8%) had z-scores − 0.5 to −2.0 and 40 (7.7%) had z-score < −2. Table 1 shows their demographic characteristics. Efficacy of first course of NSAIDs was not different among these birth weight groups (Table 2). There was no difference in the side effects and neonatal morbidities amongst the three groups (Table 2). Multivariate logistic regression analysis after controlling for GA, gender, antenatal steroids, C-section, and SNAP II showed that the odds of PDA ligation was significantly higher among infants with BW z-score < −2 (aOR 2.68, 95% CI 1.13- 6.36) but not among infants with z-score −0.5 to−2.0 (aOR 1.41, 95% CI 0.84, 2.39) as compared to z-score >-0.5. Conclusion Preterm severe IUGR infants with z-score < −2 have an associated increased risk of PDA ligation following pharmacologic treatment as compared to normally grown infants.

Most clinicians rely on outcome data based on completed weeks of gestational of fetal maturity for antenatal and postnatal counseling, especially for preterm infants born at the margins of viability. Contemporary estimation of gestational maturity, based on ultrasounds, relies on the use of first-trimester scans, which offer an accuracy of ±3–7 days, and depend on the timing of the scans and the measurements used in the calculations. Most published literature on the outcomes of babies born prematurely have reported on short- and long-term outcomes based on completed gestational weeks of fetal maturity at birth. These outcome data change significantly from one week to the next, especially around the margin of gestational viability. With a change in approach solely from decisions based on survival, to disability-free survival and long-term functional outcomes, the complexity of the parental and care provider’s decision-making in the perinatal and postnatal period for babies born at less than 25 weeks gestation remains challenging. While sustaining life following birth at the margins of viability remains our priority—identifying and mitigating risks associated with extremely preterm birth begins in the perinatal period. The challenge of supporting the normal maturation of these babies postnatally has far-reaching consequences and depends on our ability to sustain life while optimizing growth, nutrition, and the repair of organs compromised by the consequences of preterm birth. This article aims to explore the ethical and medical complexities of contemporary decision-making in the perinatal and postnatal periods. We identify gaps in our current knowledge of this topic and suggest areas for future research, while offering a perspective for future collaborative decision-making and care for babies born at the margins of viability.

Aim: To evaluate the impact of outreach education targeting neuroprotection on outcomes of outborn infants with moderate-to-severe hypoxic ischemic encephalopathy (HIE). Methods: A retrospective cohort study of infants admitted with moderate-to-severe HIE was conducted following the implementation of outreach education in January 2016. Key interventions were early identification and referral of infants with encephalopathy utilizing telemedicine and a centralized communication system, hands-on simulation, and interactive case discussion and dissemination of clinical management guidelines and educational resources. The association between the intervention and a composite outcome of death and/or severe brain injury on brain magnetic resonance imaging (MRI) was tested controlling for the confounding factors. Results: Of 165 neonates, 37 (22.4%) died and/or had a severe brain injury. This outcome decreased from 35% (27/77) to 11% (10/88) following the implementation of outreach education (P<0.001). Eligible infants not undergoing therapeutic hypothermia within 6 hours from birth decreased from 19.5% (15/77) to 4.5% (4/88). The use of inotropes decreased from 49.3% (38/77) to 19.6% (13/88). Any core temperature below 33 degrees C was recorded for 20/53 (38%) before and 16/78 (21%) after, while those within the target range of 33 degrees C to 34 degrees C at admission to a tertiary care facility increased from (15/53) 28% to (51/88) 58%. Outreach education was independently associated with decreased composite outcome of death and/ or severe brain injury on MRI (adjusted odds ratio 0.2; 95% confidence interval 0.07 to 0.52). Conclusion: Outreach education targeting neuroprotection for infants with moderate-to-severe HIE was associated with a reduction in death and/or severe brain injury.

There is a large body of evidence demonstrating that delaying clamping of the umbilical cord provides benefits for term and preterm infants. These benefits include reductions in mortality in preterm infants and improved developmental scores at 4 years of age in term infants. However, non-breathing or non-vigorous infants at birth are excluded due to the perceived need for immediate resuscitation. Recent studies have demonstrated early physiological benefits in both human and animal models if resuscitation is performed with an intact cord, but this is still an active area of research. Given the large number of ongoing and planned trials, we have brought together an international group that have been intimately involved in the development or use of resuscitation equipment designed to be used while the cord is still intact. In this review, we will present the benefits and limitations of devices that have been developed or are in use. Published trials or ongoing studies using their respective devices will also be reviewed.

Objective SBAR (situation, background, assessment and recommendation) is a structured format for the effective communication of critically relevant information. This tool was developed as a generic template to provide structure to the communication of clinical information between health care providers. Neonatal transport often presents clinically stressful circumstances where concise and accurate information is required to be shared clearly between multidisciplinary health care providers. A modified SBAR communication tool was designed to facilitate structured communication between nonphysician bedside care providers operating from remote sites and physicians providing decision-making support at receiving care facilities. Prospective interventional study was designed to evaluate the reliability of a “SBAR report to physician tool” in sharing clinically relevant information between multidisciplinary care providers on neonatal transport. Study Design The study was conducted between 2011 and 2014 by a dedicated neonatal transport service based at McMaster Children's Hospital which provides care for approximately 500 infants in Southern Ontario annually. In the preintervention phase, 50 calls were randomly selected for the evaluation and 115 consecutively recorded transport calls following adoption of the reporting tool. The quality of calls prior to and after the intervention was assessed by reviewers independently. Inter-rater agreement was also assessed for both periods. Results Inter-rater agreement between raters was moderate to perfect in most components of the SBAR “report to the physician tool” except for the assessment component, which showed fair agreement during both preintervention and postintervention periods. There was an improvement in global score (primary outcome) with a mean difference of 0.95 (95% confidence interval [CI]: 0.77–1.14; p < 0.001) and in cumulative score with a mean difference of 8.55 (95% CI: 7.26–9.84; p < 0.001) in postintervention period. Conclusion The use of the SBAR report to physician tool improved the quality of clinical information shared between nonphysician members of the neonatal transport team and neonatal transport physicians. Key Points